research

Gestational Weight and Dietary Intake During Pregnancy: Perspectives of African American Women

Mable Everette

Published online: 7 November 2007

� Springer Science+Business Media, LLC 2007

Abstract Objectives This investigation explored the

participants’ perspective on weight, nutrition, and dietary

habits during pregnancy. The data of interest were culled

from a larger ethnographic research study designed to

gather information and ideas about the socio-cultural,

psychological, and behavioral influences on maternal

health during pregnancy (N = 63). Methods My study

focused on the six participants (including three teenagers)

who delivered low birth weight and/or preterm babies and

13 participants aged B18 years (teenagers) who delivered

normal weight babies. Data were analyzed utilizing quali-

tative methodology. Results Four of the participants who

delivered low birth/weight preterm infants reported weight

related concerns during pregnancy. These included: weight

loss, lack of weight gain, and exceeding their expected

weight gain. Frequently, the nutrition knowledge was based

on miseducation, misconceptions, and/or ‘a grain of truth’

i.e. folk beliefs. Support group members had an influential

role on participants’ dietary habits during pregnancy.

Conclusion The next step appears to be more qualitative

work, with health care providers, the Women Infants and

Children Program (WIC) nutrition counselors, clinical

dietetic professionals, and women who already have chil-

dren, to explore strategies for improving diet quality as

well as address the issue of inadequate and excessive

weight gain during pregnancy.

Keywords Qualitative research � Pregnancy � African American women � Nutrition � Dietary intake � Gestational weight

Introduction

The Centers for Disease Control and Prevention reported

that the rate of preterm births (\37 completed weeks of gestation) had increased 30% in the last two decades [1].

African American women deliver their infants at 37 weeks

gestation twice as often as women of other races and deliver

their infants before 32 weeks of gestation three times as

often as white women [1]. The same ethnic disparity is also

evident for low birth weight (\2,500 g/5.51 lb). In 2001, for singleton births, the rate was 4.9% for non Hispanic

whites and 11.9% for non Hispanic blacks [2].

Little is known about why African American infants are

at risk of adverse outcomes. Many believe that scientists

must take a fresh look at the problem and approach it from

a different vantage point [3]. Rowley [4] purported that

understanding the cause of the gap in preterm delivery and

the potential interventions to eliminate this disparity

required a multidisciplinary approach; this methodology

would elucidate the biological pathways, stressors, and

social environment associated with preterm birth.

The aim of this analysis was to describe the participants’

perspective on weight, nutrition, and dietary habits during

pregnancy. I examined the hypothesis that gestational

weight, nutrition information/knowledge, and dietary hab-

its are associated with neonatal weight outcome. In order to

test the hypothesis, the analysis included the most vulner-

able participants: (1) six participants (50% of whom were

teenagers) delivering low birth weight and/or preterm

babies and (2) 13 teenagers who delivered normal weight

babies.

MC Ganity et al. [5] define a biologically mature female

as a young woman who is at least 5 years postmenarchal.

The growth demands of the pregnancy and the fetus

superimposed on the growth demands of an adolescent

M. Everette (&) Community Nutrition Education Services, Inc, 110 S LaBrea

Avenue, #213, Inglewood, CA 90302, USA

e-mail: [email protected]

123

Matern Child Health J (2008) 12:718–724

DOI 10.1007/s10995-007-0301-5

during the first year after menarche may result in undesir-

able reproductive outcomes [5]. Maternal age younger than

18 years of age and 35 years or older has been associated

with preterm birth, but the effect seems to be confined to the

female who has never borne an offspring [6].

Among the other factors that have been implicated as

possible contributing factors to preterm delivery are: low

pregravid weight; inadequate weight gain during preg-

nancy; iron deficiency anemia early in pregnancy; and poor

diet [7].

A positive relationship between weight gain and birth

weight has been consistently reported in both developing

countries and among different ethnic groups [8, 9].

Maternal pregravid weight or Body Mass Index (kg/m 2 )

and weight gain appear to have independent and additive

effects on birth weight outcome [10]. Although total weight

gain is an important predictor of birth weight, the pattern of

weight gain and rates appear to play a significant role in

predicting preterm delivery [10–12]. Scholl [13] noted that

the increasing evidence for an association between low

rates of maternal weight gain and preterm delivery does not

imply causality. The importance of optimal body mass

index (BMI) at the start of pregnancy was emphasized in a

study conducted by Jain et al. [14]. The researchers noted

that of the women considered overweight or obese before

conceiving, more than half gained excessive weight during

pregnancy [14].

Poor maternal nutrition status (diet low in most neces-

sary food nutrients) has been implicated as a possible

contributing factor to preterm delivery [7]. In terms of

overall calories, after controlling for confounding vari-

ables, women with inadequate gestational weight gain

consumed fewer kilocalories/day (-173 kcal/d) than did

those women whose pregnancy weight gain was adequate

for gestation [13]. Sufficient energy is a primary dietary

requirement of pregnancy. If energy needs are not met,

available protein, vitamins and minerals cannot be used

effectively. Limited information is available regarding the

nutrient needs of pregnant adolescents [15, 16].

When detected early in pregnancy, iron deficiency

anemia was associated with a lower caloric and iron intake,

an inadequate gestational weight gain over the whole

pregnancy, as well as with a greater than twofold increase

in the risk of preterm delivery [13, 17].

Vitamins and minerals, referred to collectively as

micronutrients, have important influences on the health of

pregnant women and their growing fetuses [18]. Previous

observational studies in both young and older gravidas

have shown that low intakes of iron and zinc were related

to preterm deliveries [13, 15]. The risk of preterm delivery

with low dietary zinc intakes was particularly strong (three-

fold increased risk) for those whose rupture of membrane

preceded labor [15]. Other studies on micronutrients await

larger studies before recommendations on their appropriate

levels of intake can be made [19].

Methods

The data of interest were culled from an ethnographic study

conducted by the Healthy African American Family I

Project (HAAF 1). The project was funded by the Centers

for Disease Control and Prevention (CDC), Division of

Reproductive Health, at the University of California Los

Angeles (UCLA) and Charles R Drew University of

Medicine and Science. The aim was to study the reasons

for low birth weight and infant mortality among African

Americans in Los Angeles, California. Data were collected

during the years 1992–1995. All of the research partici-

pants were selected using a convenience sampling

methodology. During the life of the project, over 100

pregnant African American women were interviewed at

home, work, or in a community setting. Sixty-three women

qualified for the HAAF1 study. Written informed consent

was obtained from all women and family and community

members interviewed. Approval to conduct the ethno-

graphic study was obtained from UCLA’s Human Subjects

Protection Committee. While women under 18 years of age

fell within the sample, pregnant minors are considered

‘‘emancipated minors’’ by the State of California, and as

such may give informed consent to participate in a research

project without the involvement of parents.

The Ethnographers were recruited and trained in quali-

tative interview technique methods including didactic

instructions, readings, practice interviews, and feedback by

the HAAF I Project’s Anthropologist. The study utilized

data triangulation methods across data sources in order to

check the data from various perspectives [20]. All inter-

views were audiotape recorded. To retain the colloquial

flavor of the client’s language, their words were reported

verbatim from the audiotapes. In those instances where the

Ethnographer or the Anthropologist felt the transcriber’s

interpretation of the taped interview was sufficiently

ambiguous, bracketed changes or substitutions were made

to aid the reader in comprehending what the client was

communicating.

Questions (of interest for this analysis) explored the

participants’ perceptions on weight, nutrition, and eating

habits during pregnancy. A semi structured open-ended

interview style was used to elicit open-ended responses.

For example, ‘‘What did you eat yesterday?’’ Probes fol-

lowed the question, for example: ‘‘So tell me what you

have been eating? What did you have yesterday? Like from

morning to evening?’’ Another question addressed prep-

regnancy weight, ‘‘How much did you weigh before you

got pregnant?’’ Probes followed the question, for example:

Matern Child Health J (2008) 12:718–724 719

123

‘‘Are you concerned about gaining weight?’’ Another

question addressed vitamin and mineral supplements,

‘‘What kind of prenatal medications were you taking?’’

Probes followed the question, for example: ‘‘So when they

gave you your prenatal vitamins and stuff like that, who

did-did you have questions or anything like that?’’

Prior to analysis of the data of interest, a coding tem-

plate was developed based on a content analysis of the

transcripts [21]. The responses were categorized under two

broad themes for all 63 subjects: (1) ‘‘Maternal Weight

Gain’’ and (2) ‘‘Eating Habits during Pregnancy.’’ The

latter category also included, ‘‘Vitamin and Mineral Sup-

plements Use.’’ Two coders independently coded the data.

Interrater reliability was 82% percent, an indication of

good consistency. These codes were reviewed by both

coders until 100% agreement was achieved. Following the

agreement, the major themes and subthemes were assigned

a code, the codebook was finalized, and the analysis was

conducted.

The study used self reported data for socioeconomic

status (SES), prepregnancy weight, and weight gained

during gestation. The height of participants was not

available for this analysis. The actual neonatal birth

weights were provided by the medical care facility.

Results

The Results for the 13 Teenagers Delivering Normal

Weight Babies Follow Each of the Tables in this

Section

The characteristics of the participants delivering preterm/

low birth weight babies are presented in Table 1. Five of

the 63 participants delivered preterm/low birth weight

babies; one subject delivered a small for gestational aged

infant at full term. This total group of six comprised 10.5%

of the total sample. One-half the participants delivering

preterm/low birth weight babies were 18 years or younger; the

other 50% were over age 18. Four of the six participants (67%)

reported themselves as being, ‘‘ low income.’’ This was the

first pregnancy for a participant under the age of 18.

The 13 teenagers (21% of total sample of 63) ranged in

age from 14 to 18 years. Ninety two percent of the teen-

agers reported themselves as ‘‘low income.’’ Fifty four

percent (n = 7) reported at least one prior pregnancy (data

not shown).

The subthemes related to weight gain during pregnancy

for those participants delivering LBW/preterm babies are

noted in Table 2. Four of the participants who delivered

LBW/preterm infants reported weight related concerns

during pregnancy. These included: lack of weight gain,

weight loss, and exceeding their expected weight gain.

The subthemes (followed by selected quotes) for the

teenagers reflected misconceptions about weight including

justifications for weight gain/loss, for example, ‘‘weight

gain not always related to being pregnant’’ and ‘‘ weight

loss was planned prior to pregnancy.’’ Subtheme: (1)

Weight gain not always associated with being pregnant.

‘‘ When I first-when I was 3 months, I put-by the time I

was 3 months, I had gained 30 lb already. I didn’t even

know I was pregnant because I was spotting still when it

was time for my period to come...when she [Aunt] took me

to the doctor and I was pregnant.’’ Subtheme: (2) Depres-

sion related to body image. ‘‘I get depressed when I look at

myself...[referring to weight gain]. That’s why I don’t look

at myself. Only my face.’’ Subtheme: (3) Planned weight

loss prior to pregnancy. ‘‘...but I lost some weight before I

got pregnant so I can get pregnant because I did not want to

weigh because then I would have been bigger so I just went

down to 112–115 something like that...then I got pregnant

so I would be an even weight when I have the baby.’’

The subthemes related to the role of diet/nutrition during

pregnancy for those participants delivering low birth

weight (LBW)/preterm babies are noted in Table 3. The

issues included skipping meals/inadequate food intake, the

role of cultural influences on food selections, and a specific

food being related to the health of the baby.

Table 1 Characteristics of participants delivering preterm/low birth weight babies (n = 6)

Age SES # Children # Previous pregnancy Education achieved Weight of new baby

18(1) Middle 2 2 12 4 lbs, 9 oz

21(2) Low 2 2 13 4 lbs, 14 oz

22(1) Low 2 2 12 4 lbs, 12 oz

14(1) Low 1 1 8 2 lbs, 13 oz

22(1) (a) Middle 0 0 12 4 lbs, 8 oz; 5 lbs, 8 oz

16(1) Low 0 0 10 5 lbs, 8 oz

(1) Indicates birth outcomes that were both pre-term and low birth weight (LBW); (2) Indicates birth outcomes that were LBW; (a) Indicates

twins; SES (self-reported socio-economic status)

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The subtheme (followed by selected quote) for teenagers

delivering a normal weight baby also reflected a specific

food being related to both the health of mother and baby.

Subtheme: Specific foods related to the health of baby. ‘‘...I

have to drink a lot of milk-I drink at least 2 gallons of milk

a week, ‘cause I love milk.’ And plus, I have to drink a lot

of milk because my mother was telling me that since I have

bad teeth, the baby will take all the milk from me, and my

teeth will start hurting.’’

The subthemes related to family/support group for those

participants delivering LBW/preterm babies are noted in

Table 4. The influence of members of the support system

was evident in the selected quotes presented.

The subthemes for the teenagers delivering normal

weight babies also reflected the role of support/family

members. The subthemes are noted as follow (subtheme/

selected quote). Subtheme: (1) Father of baby. ‘‘She got a

lot of cravings, too. All of a sudden. Once she gets finished,

like, she’ll say, pour her some juice, and she finished that, I

want some of this, some of that, you know, so it builds up.

So I guess I have to get used to that.’’ Subtheme: (2)

Mother of one teenager. ‘‘She [mother] started keeping,

since I like to snack, she started keeping like fruits and I

like fruits, I just, it never was around.’’

Other findings: The subthemes related to the use of

prenatal vitamin and mineral supplements for participants

delivering pre/term low birth weight babies. (1) ‘‘Took

prenatal vitamins, calcium and iron.’’ (2) ‘‘Prenatal vita-

mins caused nausea and vomiting when taken on an empty

stomach.’’ (3) ‘‘Three times a day [iron and calcium] and

then a prenatal vitamin once a day.’’

The subthemes related to the use of vitamin and mineral

supplements for the teenagers delivering normal weight

babies are noted as follow: (1) ‘‘Started taking supplements

Table 2 Gestational weight gain subthemes for the participants delivering low birth weight/preterm babies

Weight focus subthemes Selected quotes illustrating themes

The lack of weight gain was noted as a sign of not

looking pregnant to others

‘‘People used to always be like, you sure you pregnant?...[I] Never got

bigger. But I used to like-I used to throw up in the end [vomiting].’’

Weight loss occurred during pregnancy ‘‘Well, I have lost weight-I went in the doctor at 183 and now I/m 170. So the

Doctor’s worried about my weight. By me dropping so much weight

[during pregnancy]...He said that, you know, you’re just need to eat

more.’’

Weight gain during pregnancy was not seen as

related to weight of baby

‘‘You know I gained 43 lbs, you know when I sit have the baby, this baby is

4 lbs and 14 ounces and I—like why it happen?’’[full term birth, delivered

@ 40 + weeks gestation.]

Exceeded expected weight gain ‘‘I ran over 5 lbs and then that was bad.’’

Table 3 Nutrition subthemes for participants delivering low birth weight/preterm babies

Nutrition/food intake sub themes Selected quotes illustrating themes

Eating habits secondary to emotional

issues

‘‘...Then for dinner, I had some cereal because I had a roommate here an um, and we

were going through some motions, you know what I’m sayin’ with her. So my mind

wasn’t really focused on eating. So I didn’t really eat too much-eat too good

yesterday.’’

Cultural influences on food intake ‘‘Been pro-Black...Don’t eat no pork. Cut off a lot of junk food. A lot of cookies and

junk food like that. Cut out a lot of fast foods.’’

Specific foods related to the health

of baby

‘‘I had some corn, some brown rice with some chicken with something on the side. But,

um, ‘cause I like brown rice better than white rice because brown rice is better for the

baby, my mom said.’’

Table 4 Family/support for women delivering pre term/low birth weight babies

Family/support group-influence on foods eaten Selected quotes illustrating themes

Father of baby ‘‘He (baby’s father) pretty much wants me to eat everything, I mean regardless to how

many calories it is or if I should eat it or if I shouldn’t eat it.’’

Mother of one teenager ‘‘And I don’t be eating a lot of junk food and candy. I used to drink beer and stuff but I

do everything in front of my mom to let her know I ain’t trying to hide, she figures as

long as I do it in front of her, it’s ok.’’

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123

when 6 months pregnant.’’ (2) ‘‘Learned how these should

be taken in a class.’’ (3) ‘‘Taking prenatal care pills, but

made me vomit.’’ (4) ‘‘Mother made me start taking.’’

There was one reference to the use of the Women Infant

and Children (WIC) Program. The Question: ‘‘How did

you find out about WIC?’’ The answer, ‘‘You know...as

part of information on the different kind of programs

available to pregnant women.’’

Discussion

The hypothesis examined was that gestational weight,

nutrition information/knowledge, and dietary habits were

associated with neonatal weight outcome. Although a wide

range of themes and subthemes emerged from the ethno-

graphic study, the data were individualized for each

participant.

Four of the participants who delivered low birth/weight

preterm infants reported weight related concerns during

pregnancy. The lack of sound, basic information related to

the importance of and the role of weight gain and its rel-

evance to the health of the infant for both the teenagers and

the participants delivering low birth weight/preterm babies

was evident.

Frequently, the nutrition knowledge was based on mis-

education, misconceptions and/or ‘a grain of truth’ i.e. folk

beliefs. Vitamin and mineral supplement intake was

problematic for participants. The support group members

had an influential role on dietary habits of participants

during pregnancy.

An important strength of the data was that the actual

birth weights were provided by the medical care facility.

Kramer [22] stated birth weight, defined as the sum result

of the rate and duration of a fetus’ growth, is a reliably

collected variable and is still frequently used as a predictor

of the mortality and morbidity of infants.

The data for this study have several limitations. The

sample size was small; larger studies are recommended. A

potential limitation is ‘‘researcher bias’’ where the

researcher’s age, sex, ethnicity, personality traits, and other

characteristics could influence what the researcher is told

or allowed to see and how he or she perceives events and

people. The larger study utilized the triangulation meth-

odology [20] in order to lessen the ‘researcher effect.’ The

study relied on the participant’s self reported information,

particularly for pregravid weight and weight gain during

pregnancy. The reliability of the self reported data gives

rise to the question: ‘‘How accurate are self-reported

data?’’ Cook and Campbell [23] pointed out that partici-

pants tend to report what they believe the researcher

expects to see, or report what reflects positively on their

own abilities, knowledge, beliefs, or opinions. Self reported

data also centers on whether participants are able to

accurately recall past behaviors. Cognitive psychologists

have warned that the human memory is fallible [24] and

thus the reliability of self-reported data is tenuous. The

semistutured interviewing techniques interwove questions

regarding pregravid weight, nutrition and dietary habits,

and vitamin and mineral supplements among the total of all

questions asked related to socio-cultural, psychological,

and behavioral influences on maternal health during preg-

nancy. The data were ascertained in different ways by

Ethnographers. The results were difficult to quantify.

This investigation explored the participants’ perspective

on weight during pregnancy. The lack of credible infor-

mation related to the importance of and the role of weight

(both inadequate and excessive) during pregnancy

appeared to be the dominant theme for all participants. In

the interviews participants usually justified weight gain

from a cosmetic point of view rather than the relationship

of weight to pregnancy outcomes. According to Hender-

son-King [25], women have long been evaluated in terms

of their appearance as contemporary North American

society has witnessed increased pressure on women to

aspire to ideal images of beauty. The exact nature of the

ideal is subject to change as fashion trends dictate; how-

ever, a focus on weight and body shape, with an increasing

trend toward slenderness has characterized the ‘‘contem-

porary ideal.’’ Harris et al. [26] further amplifies this theme

noting that very few empirical studies to date have ade-

quately examined non-white women’s attitudes toward

their bodies. The researchers further noted that absent

from existing studies is an examination of the demographic

and socio-cultural variables that related to the perception of

and feeling toward the body among African American

women.

The second focus of this study was an examination of

nutrition information and dietary habits in the context of

the environmental and family situations. An important

component of note was the influence of family/support

group members in determining/overseeing foods eaten by

the participants.

The research of Mullings et al. [27] noted that preg-

nancy served to mobilize greater action by women to

address housing, environmental and economic, and other

social stressors that existed before pregnancy; among these

were an active attempt to assess quality health care and

nutrition. Chomitz et al. [28] purported that the health

behaviors should not be isolated from the environment

(society, community, and family) that fosters and support

them, and thus a change in the elements within the envi-

ronment will facilitate an individual’s ability to change

behaviors. Bronner [29] stated that nutrition counseling has

not been as family centered as it could be. The involvement

of the pregnant client’s network of support in the nutrition

722 Matern Child Health J (2008) 12:718–724

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and health education counseling would begin to address the

family centered concept.

Further Research and Conclusion

Multi-disciplinary research approaches have been recom-

mended in order to determine the complex factors that are

involved in preterm birth [4, 30]. Further studies that group

outcome measures according to the proximate causes of

preterm delivery and target individuals (versus popula-

tions) at risk are required to determine whether poor

nutrition is a marker for or cause of preterm birth. Access

to medical records in order to obtain prepregnancy weight

as well as gestational weight gain would serve to

strengthen the study results. Evidence suggests that popu-

lations at high risk of preterm births appear to have a

poorer quality diet [11, 31]. Thus, the research should focus

on macronutrients as well as micronutrients and the rele-

vance to preterm/low birthweight infants.

The next step appears to be more qualitative work, with

health care providers, the Women Infants and Children

Program (WIC) nutrition counselors, clinical dietetic pro-

fessionals, and women who already have children, to

explore strategies for improving diet quality as well as

address the issue of inadequate and excessive weight gain

during pregnancy.

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